History
A 37-year-old woman is seen in the clinic because of infertility. She is gravida 3 para 1 having had a daughter 13 years ago and a miscarriage 2 years later. She separated from her former husband and has now married again and is keen to conceive, especially as her new partner has no children.
Her last period started 45 days ago. She says that her periods are sometimes regular but at other times she has missed a period for up to 3 months. The bleeding is moderate and lasts up to 4 days. There is no history of pelvic pain or dyspareunia, and no irregular bleeding or discharge. Alcohol intake is minimal and she does not smoke or take other drugs. There is no medical history of note and she takes no regular medication. Her partner is 34 years old and is also fit and healthy with no significant history of ill-health or medications.
Examination
There are no abnormal features on examination of either partner.
Questions
• What is the cause of the infertility?
• What are the further investigation and management options?
Medicine
Women with irregular periods often do not ovulate. Anovulation in this case is confirmed by the low day 21 progesterone level. The commonest cause of anovulation is polycystic ovaries, but in this case the ovaries show normal morphology and the androgen levels are normal.
The noticeable abnormality is the high FSH level and the fact that no follicles are visual-ized at ultrasound scan. This is suggestive of anovulation from premature failure of ovar-ian function. The woman is not menopausal because she still has periods although irregular, and the FSH is only marginally raised. However it is known that FSH levels above 10 IU/L are associated with a poor prognosis for conception using the woman’s own ova.
Further investigation.
The FSH should be repeated, as it is possible that this could be a sporadic result or poorly timed sample, and therefore confirmation is needed before continuing on to treatment.
Management
As there is such a poor prognosis for conception either naturally or with in vitro fertiliza-tion using the woman’s own ova, she should be counselled about assisted conception using donor eggs. Donated oocytes are fertilized with the partner’s sperm and then implanted into the uterus. The woman needs appropriate luteal phase support, most com-monly with progesterone pessaries.
KEY POINTS
• FSH above 10 IU/L is associated with poor prognosis for fertility.
• Infertile couples should be encouraged to explore all options, including accepting
childlessness and adoption as well as assisted conception techniques.
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